PHTH1110 009 Principles of Non Operative Fracture Management - Wright.pdf

PRINICIPLES OF NONOPERATIVE FRACTURE MANAGEMENT NON-OPERATIVE FRACTURE MANAGEMENT - DEFINITION Mechanical, physical or non-surgical method used to promote fracture healing PHILOSOPHY All fractures can be treated All fractures can be treated nonoperatively??? - Charnley Non-Operative Fracture Managem...

PRINICIPLES OF NONOPERATIVE FRACTURE MANAGEMENT NON-OPERATIVE FRACTURE MANAGEMENT - DEFINITION Mechanical, physical or non-surgical method used to promote fracture healing PHILOSOPHY All fractures can be treated All fractures can be treated nonoperatively??? - Charnley Non-Operative Fracture Management GOAL Union in best anatomical position compatible with maximal functional return of the extremity or bone involved Canale & Beaty: Campbell's Operative Orthopaedics, 11th Ed CASTS Casts PLASTER OF PARIS quick-setting gypsum plaster fine white powder (calcium sulfate hemihydrate) preparation from the abundant gypsum found near Paris prepared by heating calcium sulfate dihydrate, or gypsum, to 120–180 °C HISTORY 3000 B.C. AD 860 Arabs Imhotep using wood splints and bandages Lime and white of eggs Paulus Aegineta circa 690 Clay gum mixtures and flour and egg white Plâtre coulé such as Eaton recorded seeing in Turkey in the 18th century Casts. Synthetic Casts Fibreglass cast Polyester cast (3D Printed Casts) TRACTION HISTORY Dr. Josiah Crosby : continuous skin traction Buck traction (1861) Sir H.O. Thomas (1876) Thomas Splint Originally TB of knee Mathijsen (1876) Plaster bandages Skull Traction CRUTCHFIELD TONGS GARDNER WELLS TONGS HISTORY Functional Bracing Gooch 1767 Sarmiento Tibia and Femoral Functional Braces PTB Mooney 1970 Hinged knee casts for Femoral cast post 6/52 traction Benjamin Gouch First Functional Brace 1767 Illustration from Paré's surgical text of 1564 of his own open tibial fracture treated by Splintage and open care of the wound. This is the first well-documented cure of an open limb fracture without amputation Early Thomas splint HISTORY SKIN TRACTION Pre-civil war As early as 1848 (Ellerslie Wallace) Efficacy popularised by Josiah Crosby Gurdon Buck 1861: Buck’s extension for treatment of femoral shaft fractures Sir Thomas Bryant Hamilton Russell: isotonic in a flexed position TRACTION Guy Chauliac: continuous isotonic traction in fracture femur treatment Poor results of angulation, shortening and rotation with isotonic traction Development of ways to overcome contraction of large thigh muscles Continuous Isometric Traction evolved Forearm skin traction for the treatment of T fractures of the distal humerus. (From Helferich, H. Frakturen und Luxationen. München, Lehmann Verlag, 1906 HISTORY - Evolution of skeletal traction Wilhem Rontgen 1895 – XRAYS Within 6 months of development of XRays malpractice lawsuits for malunited fractures Development of more effective methods of traction HISTORY Malgaigne’s hooks (1847) Grasped bone Used initially in management of displaced patella fractures Progression from hooks to tongs (Joseph Ransahoff) Tongs applied to femoral condyle (WWI) Pearson’s tongs and attachment to Thomas Splint for Fracture Femur management HISTORY Complications (infection) reduce tong use Steinman (1907) 2 pins in femoral condyles Steinman refined technique – through and through pin (popularised by Bohler) Kirschner pins ADVANTAGES Less initial cost than operative management * Non-invasive or minimally invasive Does not interrupt natural healing process Avoid complications of surgery Infection Anaesthesia Technical errors DISADVANTAGES Operator Dependent Frequent follow-up with radiographs Longer period of immobilisation with Potential of systemic complications Deep vein thrombosis Pulmonary Embolism Effects on joint and muscle function Loss of productive time Non-Operative vs Operative Fracture Management Best possible final range of movements and function in the long term INDICATIONS - Acceptable Angulation Femur in Child Age Varus/ Valgus (°) Anterior / Shortening Posterior (°) (mm) 0 – 2 yrs 30 30 15 2-5 yrs 15 20 20 6-10 yrs 10 15 15 11 yrs maturity 5 10 10 INDICATIONS - Acceptable Alignment Diaphyseal Tibia < 8 years > 8 years Adult Valgus 5° 5° 5kg required for reduction Skin sepsis TRACTION – INDICATION (SKELETAL) > 5 kg weight needed to achieve or maintain reduction Prolonged traction necessary > 1-2/52 Fractures outlined under skin traction TRACTION - BENEFITS Allows joint motion while maintaining alignment Reduce Oedema elevation above the level of the heart TRACTION - EQUIPMENT SKIN Adhesive tape Cast padding Spreader bar Rope TRACTION - EQUIPMENT SKELETAL 1) Kirschner wire and bow 2) Steinman pin and bow TRACTION EQUIPMENT POINTS TO REMEMBER Non-Threaded wire or pin Smaller More uniform Less easily broken More easily inserted Removed with less twisting than threaded TRACTION EQUIPMENT POINTS TO REMEMBER Non-threaded wire or pins Slide laterally through skin and bone Move enough to disturb traction or predispose of pin tract infections TRACTION EQUIPMENT POINTS TO REMEMBER Threaded pins or wires Stress riser at each thread Breaks more easily Must be larger in diameter to get the same strength Takes a longer time to insert Prevents lateral slippage Indicated for longer term traction (> 1-2/52) TRACTION EQUIPMENT POINTS TO REMEMBER Pins or Wires have 2 types of point Trocar Diamond-shaped Too large a hole Dull Off centre Bent TRACTION - SITES Skull Elbow (olecranon) Distal Femur Tibia Calcaneus TRACTION – COMPLICATIONS Distraction at fracture site Distal Oedema Vascular Obstruction Peroneal Nerve Palsy Skin Necrosis Compartment Syndrome CASTING - POP Impregnated crinoline with plaster of paris Anhydrous transformation to crystalline form(gypsum) in an exothermic reaction Thicker the plaster and warmer the water of immersion the greater heat produced CASTING - POP Interlocking crystals formed = strength + rigidity of the cast Critical setting period = interlocking crystal plaster creamy thick→rubbery→ loses wet, shiny appearance CASTING -POP Motion during critical setting period interferes with interlocking process and reduces ultimate strength by 77% CASTING -POP Drying occurs with evaporation of water not needed for crystallization Drying affected by air temp, humidity and circulation about the cast Thick casts take longer to dry CASTING -POP Strength increases with drying Additives to alter setting time Extra-fast setting 2-4 minutes Fast setting 5-6 minutes Slow setting 10-18 minutes CASTING - INDICATIONS Immobilise Allow earlier ambulation CASTING Best mode of application debatable Skin tight Allows motion at fracture site Loose cast with 3 point fixation Satisfactory immobilisation CASTING – Three point fixation Molding at proximal and distal portions of the extremity (2 of the points) 3rd point is opposite the apex of the cast Periosteal or other soft tissue usually required on the convex side of the cast to provide stability CASTING – Three point fixation “ If a fracture slips in a well applied plaster, then the fracture was mechanically unsuitable for treatment by plaster and another mechanical method should have been chosen” John Charnley CASTING – FIBRE GLASS Developed to replace Plaster of Paris Fibre Glass fabric impregnated with polyurethane resin Prepolymer Methylene bisphenyl diisolynate converts to a non-toxic polymeric urea substitute in an exothermic reaction CASTING – FIBRE GLASS Exothermic reaction does not put skin at thermal injury risk Preferred except in acute fractures where reduction maintenance critical Does not increase skin pressure when compared to plaster casts CASTING – FIBRE GLASS ADVANTAGE Strong Lightweight Resist Breakdown in water Radiolucent Available in multiple colours and pattern CASTING – FIBRE GLASS DISADVANTAGE Harder to contour than POP Polyurethane irritates skin Harder to apply (newer bias stretch material) CASTING – COMPLICATIONS Compartment Syndrome Burns Skin pressure necrosis Nerve Palsy CASTING – APPLICATION Pad bony prominences Plasters should be dipped and removed at the same time – at the same stage in the setting process Maximizes interlocking of crystals Maximizes cast strength Reduces delamination between bandages CASTING – APPLICATION Immobilise as few joints as possible Immobilise joint above and below a fresh fracture Post application instructions Compression symptoms Elevation Physiotherapy of other joints Return sos CASTING – APPLICATION Temperature Reinforce across joints Once critical period of interlocking begins molding and all motion should stop until material becomes rigid – weakens otherwise FUNCTIONAL CASTING OR BRACING Denhe and Sarmiento Total Contact Cast Based on Hydraulic Principles that fluids are not compressible A and B, Bamboo functional bracing currently in use in Sri Lanka. FUNCTIONAL CASTING OR BRACING Snug cast (Total Contact) maintains tissues and fluids of the area being casted in a rigid container Shortening prevented Allows weight bearing soon after fracture Improved fracture healing through increased vascularity through ambulation STRAPPING OR TAPING Limits motion of injured part Support and Stability STRAPPING OR TAPING INDICATIONS Tubular bones Dislocated joints OTHER TREATMENT MODALITIES Bed Rest Jones Bandage Orthoses Rigid Semi-Rigid CONSERVATIVE ADJUNCTS Nutrition Growth Factors and Related Molecules Systemic Enhancement Physical Enhancement Ice CONSERVATIVE ADJUNCTS Nutrition Calcium and Phosphorus Vitamin D Other Supplements CONSERVATIVE ADJUNCTS- Growth Factors and Related Molecules/ Biological Methods Bone Morphogenetic Proteins Transforming Growth Factor – ß Autologous Bone Marrow Injection CONSERVATIVE ADJUNCTSSystemic Enhancements Parathyroid Hormones CONSERVATIVE ADJUNCTSPhysical Enhancement Mechanical Stimulation Electrical Stimulation controlling WB status Constant DC Stimulation Capacitative coupling Time varying inductive coupling by magnetic field Ultrasound Stimulation Low-impulsed Pulsed Ultrasound Stimulation COMPLICATIONS OF NONOPERATIVE MANAGEMENT Fracture Malalignment with malunion Overdistraction of fracture COMPLICATIONS CONT’D Local (dependent on device used) Skin irritation / allergic reactions Skin pressure necrosis Pin tract infection Compartment syndrome Neuropraxia Systemic REHABILITATION Starts immediately depending on fracture and soft tissue stability Mobilise adjacent joints ASAP Sooner the adjacent joint mobilised the better range of motion Some joints tolerate immobilisation better than others REHABILITATION – JOINT MOBILISATION CAST ON: - ROM Adjacent not immobilised joints - Isometric exercises of immobilised muscles - Benefit of improved nutrition, decrease atrophy of articular cartilage, bone and muscle - Reduces oedema and rehabiliation required post cast removal REHABILITATION – JOINT MOBILISATION CAST OFF: - Elastic stocking for support - Specific Exercise programme to promote ROM - Active Exercises - Joint motion slow to return and poor in range if attempted motion produces pain, associated muscle spasm and involuntary splinting (ANALGESICS) REHABILITATION – JOINT MOBILISATION ❑ ❑ ❑ Normal joint tolerates longer periods of immobilisation except elderly Early joint motion may delay fracture healing if fixation not rigid Post injury or casting oedema “glue”: fibroblast in area→ xs collagen formation→ early, frequently permanent stiffness REHABILITATION Physical therapy Active Active assisted Range of motion and strengthening Weight Bearing limited Progression monitored radiologically according to evidence of stability and bone regeneration Intra-articular NWB x 3/12 but encouraged early motion SUMMARY Choice of non-operative vs. operative dependent on best function after healing Has a role in present day management There are specific indications dependent on bone involved Monitor closely clinically and radiologically Low threshold to convert to operative management early in pointing to treatment failure SUMMARY Adjuncts to optimum management Rehabilitation is key irregardless of mode of treatment selected References Browner. Skeletal Trauma, 4th Edition. Elsevier 2009 Bucholz. Rockwood and Green’s Fractures in Adults, 5th Edition. Lippincott 2001 Canale & Beaty. Campbell’s Operative Orthopaedics, 11th Edition. Elsevier 2008 Connolly J. Fractures and dislocations – closed management. Philadelphia: WB Sanders; 1995 Charnley J. The closed treatment of common fractures, 3rd Edition. Cambridge: Colt Books; 1999 Peltier L. A Brief history of traction. J Bone Joint Surgery 1968; 50A: 1603-1617 Swiontkonski M. Manual of Orthopaedics, 6th Edition. Lippincott 2005